Young mothers’ attitudes towards domestic violence and their maternal healthcare services utilization in Bangladesh: A multilevel cluster analysis

This paper examined the association between young mothers’ attitudes towards domestic violence and four or more antenatal care (ANC) and health-center-based delivery service utilization using two cross-sectional waves of the Bangladesh Demographic and Health Surveys (2014 and 2018) data. We carried out a multilevel logistic regression analysis. Findings show that a strong cluster variation exists in four or more ANC and health-center-based delivery service utilization. Although the utilization of four or more ANC and health-center-based delivery services has increased over the years, it is far behind the targets of SDGs, particularly for young mothers with justified attitudes towards domestic violence. Extension of maternity allowance coverage and motivational programs are important policy recommendations.


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We used secondary data which is available for public use. Thus ethical clearance is not required for this study.  Assurance of healthy lives for all is one of the commitments of the Sustainable Development Goals 18 (SDGs), the blueprint for building a better world for the next generation. In achieving equity in the 19 health systems, a reduction in maternal mortality is greatly desirable which can be ensured through 20 access to and use of quality antenatal care (ANC) and health-center-based delivery care. Utilization 21 of four or more ANC and health-center-based delivery care is an important WHO-recommended 22 strategies to reduce preventable maternal mortalities and their morbidities (1-3). Moreover, young 23 mothers have a greater risk to experience maternal mortality due to their limited access to four or 24 more ANC and health-center-based delivery care compared to adult mothers (4-7). Previous 25 studies have identified several barriers of four or more ANC and health-center-based delivery 26 service utilization related to demographic and socio-economic aspects of the population. Apart 27 from these, the association of behavioral factors, especially the attitudes of young mothers towards 28 domestic violence and access to four or more ANC and health-center-based delivery care need to 29 be explored as it has become a burning issue over the world now-a-days. The international 30 community has also been committed to ending all forms of violence against all women and girls      The association between domestic violence and the lower utilization of four or more ANC and     The study considered two binary outcome variables as indicators of maternal healthcare services 128 utilization. The first outcome variable, utilization of four or more ANC visits categorized into two: 129 'yes' refers to those who had four or more ANC visits, and 'no' refers to those who took zero to  The prime focus of this study is on the independent variable 'young mothers' attitude toward 137 domestic violence'. A composite variable was measured through young mothers' attitudes towards 138 justification of wife-beating or hitting by their husbands, which was grounded by their responses

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The distribution of young mothers aged 15-24 years by background characteristics presented in 185 Table 1 shows that the percentage of young mothers with four or more ANC visits was increased proportion of first birth order was higher for young mothers in both years.
196     There was a significant geographical variation in using four or more ANC and health-center-based 233 delivery services (Table 3). In terms of using health-center-based delivery Sylhet division had been 234 identified as a low-performing area of all divisions for both of the study points (24.3% and 42.8% was increased by 14.1% and 12.7% respectively for young mothers with access to media.
256 Surprisingly, employed young mothers compared to unemployed were significantly less prevalent 257 in using health-center-based delivery care in both years. Young mothers were used four or more 258 ANC and health-center-based delivery care more for their first birth compared to any other births.

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However, there was a 14.7% increase of four or more ANC (26.9% to 41.6%) and an 11.2% 260 increase in health-facility-based delivery care (28.6% to 39.8%) in terms of the births other than 261 the first birth between the two survey waves. However, women's decision-making capacity was 262 not found significant in any of the years for both of the outcomes.  From the adjusted covariates (Table 4) The odds ratio of four or more ANC and health-center-based delivery care was increased with 283 improved wealth status (Table 4). The same pattern in odds ratio was found by young mothers' services among clusters due to geographic, cultural, and socio-economic differences is another 345 public health concern in Bangladesh that needs to be addressed to make healthcare services more 346 accessible to all women.

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The present study suggests that along with domestic violence, multiple socio-economic and 348 demographic covariates are significantly associated with the lower utilization of four or more ANC 349 and health-center-based delivery care. Geographical variation is also found significant for reducing 350 the use of four or more ANC and health-center-based delivery care. Unlike other studies, we also found that the utilization of four or more ANC and health-center-  The findings of the study demonstrate that though the utilization of four or more ANC and health-391 center-based delivery care has increased over the years, young mothers with justified attitudes 392 towards domestic violence are less likely to use of four or more ANC and health-center-based 393 delivery care than mothers with opposite attitudes. A strong variation in the clusters, which is 394 identified in our study, is also associated with lower utilization of health services for four or more